What is the difference between a PBM and a payer?
Develop the optimal pharmacy benefit plan for self-funded clients. You must first understand payers and their influences, then determine how to best position your customers to thrive in the environment we live in. This discussion is intended to help you determine the place of taxpayers in relation to other parties and the instruments at their disposal to participate in the discussion.
Critical factors influencing prescribing decisions
Most prescriptions are chosen between the patient and the doctor, with the provider’s professional knowledge likely leading the discussion. These two people actually determine which prescriptions are written, which are filled and which are ultimately paid. You will see the pharmacy listed in this rendering. Years ago, I would have answered that the pharmacy had minimal power because a decision had already been made by the time an item arrived at the pharmacy. Yet specialty pharmacies now wield much more influence. They currently represent 50% of the costs. Therefore, I would say that pharmacy has an increasing influence on what is dispensed, when and how.
Trying to influence the decision rather than paying the bill
Outside the immediate environment of the point of care and dispensation. The other parties have a say in what is prescribed and when. Pharmaceutical manufacturers have direct advertising contact with patients and a very close relationship with prescribers. They’ve been there from the moment they enter medical school until they hang up the stethoscope, helping them better understand the clinical utility of their products. Additionally, they work with Pharmacy Benefit Managers (PBMs). They work with PBMs to access forms and pay reimbursements. The PBM retains part of the proceeds flow from reimbursement, while the rest is distributed to the payer. In addition, they maintain a relationship with the pharmacy, especially when it comes to specialized pharmacies, through discounts on purchases. They have a great influence on their position in the market and how they can improve their market share.
Through the distribution point, PBMs interact with the immediate circle. They have a claims payment system, which is ultimately responsible for determining what is paid or not paid, based on forms and clinical standards. As you can see, neither the payer, nor the manufacturer, nor the PBM are represented at the point of service or immediate dispensation. How does a payer acquire the ability to influence what happens?
Balancing clinical and economic value
Your only entry ticket is through the PBM. Whether you are a small employer or even a large organization, navigating the world of PBM is essential to ensure you get the best pricing, reimbursement, and usage. Are you able to do this? Are you able to handle this on your own?
The beauty of SpectrumPS is that as a Pharmacy Benefit Optimizer (PBO), we are able to leverage the buying power of all of our customers to negotiate better network reimbursement contracts and discount rates. and improving the management of clinical programs. We can influence the phasing out of low-value drugs or separate PAs from PBMs, allowing them to act independently and transparently. There are many things we can do to help that employer align their goals with some of the parts of the inner circle. A more specific statement would ensure that other members of this primary and secondary circle are more aligned with the employer.
Drug producers are neither good nor bad. PBMs are neither good nor bad. Its objective is to promote therapeutically appropriate drugs. Patients and doctors are generally nice people. Again, its stated objective is to prioritize clinical effectiveness. However, neither of these parties always cares about the economy of a decision. Manufacturers don’t visit doctors to discuss their products in-depth or discuss the cost of their treatments; discuss clinical effectiveness. Often doctors are not informed of the relative cost of a prescription. So, a treatment like Duexis may seem appealing to a doctor because it has coupons and your membership won’t be required to pay a copayment. Duexis can cost up to $2,600, while over-the-counter equivalents can cost as little as $20.
This type of discrepancy occurs in today’s society and certainly does not align with the employer’s objective. Our goal is to ensure we can fit in to help neutralize it and meaningfully involve the employer in the decision-making process to help reduce costs.
